MIPCA acute treatment of migraine guideline

The acute treatment of migraine

Principles of acute migraine management

From the outset, institute systems of detailed history taking, patient education, and eliciting their commitment to care

Use a screening algorithm (see below) for the differential diagnosis of headache. The final diagnosis can then be confirmed by further questioning, if necessary

Select an acute treatment that is tailored to the needs of the individual patient, using a management algorithm (see last page of this guideline). Assessing the impact of headache on the patient’s daily life with the Migraine Disability Assessment Test or The Headache Impact Testquestionnaire is a key aspect of diagnosis and management

Only prescribe treatments that have objective evidence of good efficacy and tolerability

Use prospective follow-up procedures and questionnaires (e.g. the Migraine Assessment of Current Therapy questionnaire) to monitor the success of treatment

Organise a team approach to headache management in primary care using GP and referral services together with community-based healthcare services (e.g. pharmacists, dentists, opticians, and other professionals)

Further details of these principles of care can be found in MIPCA Newsletter Number 8, available to download from the MIPCA website (www.mipca.org.uk)

Screening algorithm

Choice of initial acute treatment

All patients should be provided with behavioural and/or physical therapies, such as:

relaxation

biofeedback

stress reduction strategies

cervical manipulation

massage

exercise

the avoidance of migraine triggers

Analgesic-based treatments, e.g. aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) in large doses, paracetamol plus domperidone, or aspirin, or paracetamol plus metoclopramide, are recommended for mild to moderate migraine. These drugs should be taken as early as possible and before the headache develops, including during the aura. However, codeine-based treatments should be avoided due to their known potential for overuse

Oral triptans are recommended for moderate to severe migraine, and should be taken as soon as possible after the headache starts, preferably when it is mild in intensity

Oral triptans remain the gold standard for acute migraine treatment

The intake of all acute treatments should be monitored, due to the risk of overuse and the development of medication overuse headache (MOH) and chronic headaches

Guidance on appropriate rescue and second-line medications is given in the table below

Appropriate medications to use when the initial migraine therapy fails

Choosing the appropriate triptan in clinical practice

Evidence indicates that all tripans, except for naratriptan 2.5 mg, have similar clinical profiles. However, the clinician should choose an appropriate initial triptan based on the chemical and clinical features of the drugs, and the needs of the individual patient

Determining the severity of the migraine is key when assessing the patient’s needs, and the MIDAS or HIT-6 questionnaire can be used for this

Patients with mild-to-moderate migraine may be effectively treated with a simple analgesic, on its own, or in combination with other compounds

Patients with moderate-to-severe migraine, and those that have previously failed on analgesic-based therapy, should be prescribed an oral triptan from the start

The algorithm below shows some features of the individual triptans that may help guide the clinician when selecting an appropriate initial treatment for their patients

Those unable to tolerate other oral triptans may benefit from almotriptan 12.5 mg, naratriptan 2.5 mg, or frovatriptan 2.5 mg

Patients that have unpredictable attacks may benefit from the orally disintegrating tablet (ODT) (although they are not absorbed in the mouth), or nasal spray formulations

Patients with particularly severe attacks, those with a need for rapid response, and those with nausea and (especially) vomiting may require the nasal spray or subcutaneous formulations

Choosing the appropriate triptan: initial treatment

Treatment of menstrual migraine

A high proportion of female patients on a GP’s list will be affected by attacks of menstrual migraine (defined as attacks occurring between two days before the onset of menstruation and the first three days of bleeding)

Attacks of menstrual migraine are usually more frequent and more severe than those occurring at other times

Management strategies for menstrual migraine are the same as those for general migraine, and there should be few problems in managing all migraine attacks experienced by women in primary care

An evidence-based review of treatments for menstrual migraine concluded that the following treatments were all effective, and had acceptable safety profiles:

sumatriptan at 50 mg or 100 mg or

mefenamic acid 500 mg or

rizatriptan 10 mg or

sumatriptan 85 mg/naproxen 500 mg combination

Further studies have demonstrated that almotriptan 12.5 mg, frovatriptan 2.5mg, and zolmitriptan 2.5mg are also effective and well-tolerated for menstrual migraine

Predictable menstrual attacks may be managed by perimenstrual prophylaxis with:

transcutaneous estradiol 1.5 mg or

frovatriptan 2.5 mg bd or

naratriptan 1 mg bd or

zolmitriptan 2.5 mg bd also showed efficacy in this indication

Strategies using contraception may be used to treat menstrual migraine in those requiring effective birth control